The Extent and Consequences of Child Maltreatment Diana J. English
Transcription
The Extent and Consequences of Child Maltreatment Diana J. English
39 The Extent and Consequences of Child Maltreatment Diana J. English Abstract Specific, accurate understanding of the extent of maltreatment in American society, the nature of the maltreatment that occurs, and the consequences it has for children are crucial to inform policies regarding child protection and to guide the design of prevention and treatment programs. This article examines how child abuse and neglect are defined and discusses the controversies that surround that definition, which attracts attention because it justifies government intervention to stop actions by parents or caregivers that seriously harm children. The article also presents statistics indicating how widespread maltreatment is, reviews research on the characteristics of families that are more prone to abuse or neglect, and summarizes knowledge about the impact of maltreatment on children. Finally, it mentions the efforts of public child protective services agencies to responsibly ration calls on their limited resources by using risk-assessment approaches to target scarce services to the children who need them the most. P ublic policies and programs addressing child maltreatment are developed based on an overall understanding of the extent of maltreatment and its consequences across the society. That understanding must be based on clear definitions of what is meant by maltreatment and accurate estimates of its prevalence nationally and locally. Data gathered from public agencies across the United States reveal that nearly three million reports of possible abuse or neglect were made to authorities in 1994, and just over one million children were found to be victims of maltreatment. The experience of maltreatment is unique to each individual child, however. Although serious consequences often result, these may depend on the intensity and frequency of the maltreatment. The child’s characteristics, relationship to the perpetrator, and access to a supportive caregiver can also influence the effects of maltreatment. Workers in child protective services (CPS) agencies need a better understanding of the dynamics of maltreatment to guide their decisions regarding the degree of risk that any given situation poses to a child. Such knowledge would also provide a foundation for The Future of Children PROTECTING CHILDREN FROM ABUSE AND NEGLECT Vol. 8 • No. 1 – Spring 1998 Diana J. English, Ph.D., is office chief of research at the Washington State Department of Social and Health Services, Office of Children’s Research, and a member of the clinical faculty at the School of Social Work at the University of Washington, Seattle. 40 THE FUTURE OF CHILDREN – SPRING 1998 the development of appropriate programs to prevent or ameliorate the effects of abuse and neglect on children. This article discusses the national definition of maltreatment and explains debates over the breadth of that definition, then examines current attempts to measure the problem. The article also reviews major factors associated with the occurrence of maltreatment and considers the consequences of maltreatment for children. Finally, the article concludes with a discussion of efforts to use this understanding to create risk-assessment systems that can help set priorities for effectively using the limited resources available for child protection. Defining Child Maltreatment The concept of child maltreatment is relatively new in Western society, although there is historical evidence that children have long been murdered, abandoned, incarcerated, mutilated, sexually exploited, beaten, and forced into labor by their parents and caregivers.1 For instance, in colonial America, children were flogged to instill discipline, and in the early twentieth century, children routinely worked 14-hour days in mills and mines.2 Such actions were not formally defined as maltreatment, however, and public authorities seldom interceded on the children’s behalf. (See the article by Schene in this journal issue.) The emergence of official definitions of unacceptable treatment of children has helped to trigger and sustain efforts by authorities to protect children. Because they have important policy implications, however, definitions of maltreatment have been hotly debated. Despite efforts to create uniform approaches, the definitions used by state legislatures, agency officials, and researchers remain ambiguous and inconsistent.3,4 Some of the key differences are discussed below. By the mid-twentieth century, legislation defining child maltreatment was introduced into many state statutes,5 and some states required physicians to report abuse or neglect.6 In 1974, the U.S. Congress passed the Child Abuse Prevention and Treatment Act (CAPTA), Public Law 93-247, to give a national definition of child maltreatment and prescribe actions states should take to protect children. That law established a broad definition of maltreatment as: “The physical and mental injury, sexual abuse, neglected treatment or maltreatment of a child under age 18 by a person who is responsible for the child’s welfare under circumstances which indicate the child’s health and welfare is harmed and threatened thereby, as determined in accordance with regulations prescribed by the Secretary of Health, Education, and Welfare.”7 This definition of child maltreatment specifies that only parents or caregivers can be perpetrators of child abuse and neglect. Abusive behavior by other individuals, whether known to the child or strangers, is considered assault. Of particular note, this national definition includes both mental injury and neglect. Definitions of the four major types of maltreatment (physical abuse, sexual abuse, neglect, and emotional abuse) are provided in Box 1. The federal CAPTA legislation sets minimum definitional standards for the states receiving federal funds, but the details of defining maltreatment fall to the states, and specific definitions vary considerably.8 For example, some states include educational neglect (when a child consistently fails to attend school) in their definition of child maltreatment, while others do not. States also vary in the criteria and procedures they use to first screen and later validate reports of alleged maltreatment.9 These variations make it difficult to compare abuse and neglect statistics across states. Nationally in 1993, an average of 42.9 children per 1,000 were reported to authorities as victims of alleged abuse or neglect, but reporting rates ranged from a low of 8.7 per 1,000 children in Pennsylvania to a high of 74.4 per 1,000 children in Idaho.10 Approximately 35% of those reports were substantiated.9 Such large differences across states complicate efforts to accurately establish the magnitude of the problem maltreatment poses on a national level. The Extent and Consequences of Child Maltreatment Box 1 Definitions of the Major Forms of Maltreatment Physical abuse: An act of commission by a caregiver that results or is likely to result in physical harm, including death of a child. Examples of physical abuse acts include kicking, biting, shaking, stabbing, or punching of a child. Spanking a child is usually considered a disciplinary action, although it can be classified as abusive if the child is bruised or injured. Sexual abuse: An act of commission, including intrusion or penetration, molestation with genital contact, or other forms of sexual acts in which children are used to provide sexual gratification for the perpetrator. This type of abuse also includes acts such as sexual exploitation and child pornography. Neglect: An act of omission by a parent or caregiver that involves refusal or delay in providing health care; failure to provide basic needs such as food, clothing, shelter, affection, and attention; inadequate supervision; or abandonment. This failure to act holds true for both physical and emotional neglect. Emotional abuse: An act of commission or omission that includes rejecting, isolating, terrorizing, ignoring, or corrupting a child. Examples of emotional abuse are confinement; verbal abuse; withholding sleep, food, or shelter; exposing a child to domestic violence; allowing a child to engage in substance abuse or criminal activity; refusing to provide psychological care; and other inattention that results in harm or potential harm to a child. An important component of emotional or psychological abuse is that it must be sustained and repetitive. Broad Versus Narrow Definitions Debates over how broadly to define maltreatment began with the drafting of the CAPTA legislation, and they have continued. Underlying the debate is the difficulty of identifying an appropriate government role in the lives of children and families. Advocates for a narrow definition of child abuse and neglect argue that before the government has a right to intervene in the privacy of a family, the parental action should have resulted in actual observable harm or pose an imminent risk of such harm. Others stress the damage that persistent neglect or psychological abuse can do to children, even if that damage appears only later.11 Thus, arguments center on whether to include mental injury and neglect, whether cumulative harm should be considered, and whether threatened as well as actual harm should count as maltreatment. Maltreatment behaviors that are associated with ongoing neglect and with repeated emotional maltreatment typically result not in a discrete injury, but in cumulative harm—the child’s well-being or developmental trajectory is impaired. For example, a parent may constantly berate a child, calling that child stupid, ugly, fat, a whore, or another pejorative term. This behavior does not cause harm that is immediate or observable, but over time the child’s sense of selfworth and ability to trust adults will be damaged.12 Similarly, cumulative harm may result if a parent neglects to provide adequate medical care. If a parent fails to take a child with chronic ear infections to a doctor for treatment, the child may lose hearing capacity, even if no life-threatening consequences ensue. The advocates for a narrow definition of child maltreatment would have excluded such actions from the concept of child maltreatment, but supporters of a broad definition prevailed when the federal definition above was established. Controversy has also surrounded the inclusion of endangerment (behavior that threatens but has not yet caused observable harm) in the definition of maltreatment. For example, if endangerment was not a standard for maltreatment, when a parent kicked a five-year-old child down a flight of stairs but no bruises or broken bones resulted, the parent’s act would not be considered abusive. If neither endangerment nor cumulative harm was included in the definition, the parent could kick the child down the stairs day in and day out without being guilty of abuse, as long as the child never experienced a physical manifestation 41 42 THE FUTURE OF CHILDREN – SPRING 1998 of injury. Even though the child might suffer serious psychological harm and there would be a potential for significant physical injury, these acts would not fit a restrictive definition of child maltreatment. As these examples suggest, the concepts adopted in definitions of child maltreatment (inclusion of neglect and mental injury; imminent risk versus cumulative harm; and actual harm versus endangerment) influence estimations of the size and scope of the maltreatment problem in the United States. They have implications for policy and practice, as well. Adoption of a narrow definition of child maltreatment would simplify the operation of a child protection system by making the determination of abuse less ambiguous, since physical A 1995 Gallup Poll of 1,000 parents yielded the estimate that 3 million U.S. children were victims of physical abuse by their parents, or about 44 per 1,000 children. evidence of bruising or a broken bone would support the finding of maltreatment. It would also restrict the number of children identified as maltreated and served by public child welfare agencies. However, since a significant number of seriously maltreated children go unnoticed even now, such a system would not necessarily keep children safe. (See the article by Waldfogel in this journal issue.) How Many Children Are Abused and Neglected? Clear definitions of child maltreatment increase the ability of researchers to count how many children are victims of maltreatment. Yet even if definitions were explicit and uniform, the true extent of child maltreatment would still be unknown. Estimates of the scope of this problem are based on cases that are mentioned by respondents in self-report surveys or reported to child protective services, but many incidents of abuse or neglect are not admitted or reported.13 Despite this difficulty, it is important to know how widespread the problem of child maltreatment is in order to anticipate the resources needed to address the problem. Two terms are commonly used to describe estimates of the extent of maltreatment in society: prevalence and incidence. Prevalence is defined as the number of people who have experienced at least one act of child abuse or neglect in their lifetime. These experiences may or may not have been reported to child protective services (CPS), the public agency charged with collecting and responding to reports of maltreatment. (See the articles by Schene and by Waldfogel in this journal issue.) Incidence is defined as the number of child maltreatment cases that come to the attention of CPS agencies each year. The incidence rate only captures children whose abuse or neglect was reported, not the number of children who were actually abused or neglected. Self-report surveys of parents and victims are used to measure the prevalence of child maltreatment, and incidence rates are measured by tallies of the official reports received by CPS agencies. Each method of measuring child maltreatment has limitations. For example, parents asked about their maltreating behavior may not disclose their actions to interviewers, and victims may not remember abusive experiences. On the other hand, not all instances of child abuse and neglect are reported, and official reports reflect the differing definitions and screening criteria adopted by states. While the exact number of children who are maltreated is unknown, the data derived from surveys and official reports provide an emerging picture of the extent of child maltreatment in U.S. society that suggests many more resources are needed to address its causes and effects. Self-Report Surveys Social surveys measuring the prevalence of maltreatment focus on reports by parents and victims of abuse or neglect that they inflicted or experienced. These surveys typically reveal rates of maltreatment higher than the rates of abuse and neglect reported to public agencies.4 For instance, the National Family Violence Survey (NFVS) interviewed nationally representative samples of families in 1976 (2,146 families) and in 1985 (3,002 families). The interviews concerned family violence and asked respondents to report on The Extent and Consequences of Child Maltreatment their own behaviors toward their children during the previous 12 months.14–16 Actions considered physically abusive were those that had a high probability of injuring a child, such as kicking, biting, punching, hitting or trying to hit a child with an object, beating up a child, burning or scalding, and shooting or threatening a child with a gun. In the 1985 survey, 20 parents per 1,000 interviewed admitted to at least one such act of violence toward their children during the previous year. The parent reports indicated that 7 per 1,000 children were hurt as a result. Projecting these percentages to the total population, one can estimate that 1.5 million children in 1985 experienced acts of violence, and 450,000 were injured at the hands of their caregivers. Even higher rates of self-reported abusive behavior were found in a 1995 Gallup Poll involving 1,000 parents. That study yielded the estimate that 3 million of 67 million U.S. children were victims of physical abuse by their parents, or about 44 per 1,000 children.17 This estimate based on parents’ reports is 16 times higher than the rates of physical abuse reported to officials.9 Sexual abuse has been studied using a variety of methods, and early studies found widely differing rates of occurrence.18 In 1985, a national survey of 2,626 adults found that 27% of the women and 16% of the men reported at least one incident of sexual abuse during their lifetime.19 These estimates were confirmed by the 1995 Gallup Poll, which found that 23% of surveyed adults reported they had been victims of sexual abuse by an adult or older child. Projected to the population, this finding represents one million child victims of sexual abuse, or 10 times the official reported rate.17 Far less information exists regarding the prevalence of the other forms of maltreatment. No national self-report studies address the extent of children’s exposure to neglect. Limited information is available on emotional abuse. In one self-report study based on a national sample of 3,346 adults, 63% of parents reported they had used at least one form of psychological aggression on their children during the previous year.20 Another form of emotional trauma for children is witnessing domestic violence.21 Data from the 1985 survey of family violence suggest that from 1.5 million to 3.3 million children witness domestic violence each year.17 In sum, self-report studies of parents suggest that several million children suffer physical or sexual abuse yearly, and that psychological abuse is even more common. Unfortunately, these studies offer no information about neglect, even though, as the studies discussed below indicate, neglect apparently affects about twice as many children as do physical and sexual abuse. National Incidence Studies Surveys of community and public agency professionals provide information on the incidence of both abuse and neglect by counting cases of maltreatment that were observed by someone outside the family. In 1974, as part of the CAPTA legislation, the U.S. Congress mandated that a National Incidence Study of Child Abuse and Neglect (NIS) be conducted periodically. This survey collects comprehensive information about child abuse and neglect from a nationally 43 THE FUTURE OF CHILDREN – SPRING 1998 44 representative sample of community-based professionals and social service agencies. Like other studies, the NIS has methodological limitations, but its strength is that it examines the characteristics of maltreatment cases that are known to professionals in the community, including cases that were not reported to authorities. Furthermore, the NIS studies conducted in 1986 and 1993 collected information about incidents that endangered a child, in addition to those incidents that inflicted actual, observable harm.13,22 Figure 1 shows how the rates of maltreatment observed by the NIS respondents changed from 1986 to 1993 for the four major categories of maltreatment. The figure also shows, on the left, the number of children identified as experiencing a maltreatment incident that resulted in harm, while the graph on the right shows those who were either endangered or harmed by an incident of abuse or neglect. (Note that all the children who were harmed are also included in the category of “endangered.”) Approximately twice as many children were The National Incidence Study found that neglect is by far the most common form of maltreatment, harming an estimated 879,000 children in 1993. endangered as were actually harmed. The category of neglect is by far the most common form of maltreatment, harming an estimated 474,800 children in 1986 and 879,000 children in 1993. Reports of both actual and potential harm to children increased significantly over the seven-year period between the two studies.13 Official Report Data The third major source of data on child abuse and neglect is official report data systems. These official records include all formal reports to public CPS agencies made by individuals in the community such as family and friends, and by professionals such as police, teachers, doctors, mental health professionals, or child care providers. A standard national system for aggregating state data on child maltreatment was developed only in 1990. Before then, several national organizations collected information periodi- cally from state agencies on reported rates of child abuse and neglect. The American Humane Association reported a 12% yearly increase in reports of child abuse and neglect to CPS agencies from 1980 to 1985.23 Picking up from that point, the National Committee to Prevent Child Abuse and Neglect surveyed the states to track the increases in reports from 1985 to 1992, and found that the number of reports rose by 6% per year. In 1985, approximately 30 children per 1,000 were reported to CPS agencies as experiencing abuse or neglect. In 1992, the rate was 45 children per 1,000.5 In 1990, the National Child Abuse and Neglect Data System (NCANDS) was established. States voluntarily contribute to this data system, which records the number and types of child abuse and neglect reports to public agencies on a yearly basis. The 1995 NCANDS report, which summarizes reports to CPS agencies in 48 participating states from 1990 to 1994, indicates a continued increase in reports of maltreatment. The number of children reported rose from 2.6 million in 1990 to 2.9 million in 1994. In 1994, the majority of referrals came from professionals (52%), and nearly half (48%) were made by friends, family, neighbors, or other citizens in the community.9 Although 2.9 million children were reported for child abuse and neglect in 1994, only 1.6 million of those reports were actually investigated. Some reports were accepted but not investigated, while others were screened out because, for instance, the eligibility criteria for investigation were not met, or the reporter did not know where the child could be located. Upon investigation in 1994, about one in three reported cases were substantiated as involving maltreatment. (See also the article by Waldfogel in this journal issue.) In that year, as Figure 2 shows, neglect was the most frequent type of maltreatment substantiated (53%), followed by physical abuse (26%), sexual abuse (14%), and emotional abuse (5%).9 In short, although there is no precise way to know the true extent of child maltreatment, its prevalence can be estimated with methods that have improved over the years. Surveys reveal that several million adults admit engaging in violent acts toward their 45 The Extent and Consequences of Child Maltreatment Figure 1 Child Abuse and Neglect Observed by Professionals: Number of Children Identified as Experiencing Harm from or Being Endangereda by Abuse or Neglect in 1986 and 1993 Harm Endangerment 2.2 2 Number of Children (in millions) 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 1986 1993 1986 1993 Year a Neglect Emotional abuse Physical abuse Sexual abuse Children who experienced harm are also included in the counts of children who were endangered. Source: Sedlak, A.J., and Broadhurst, D.D. The Third National Incidence Study of Child Abuse and Neglect. Washington, DC: U.S. Department of Health and Human Services, 1996. children each year, and many more adults recall abusive experiences as children. The number of official reports of child maltreatment has risen in every category each year since the CPS system was established. These increases have strained the capacity of state and local governments to respond and to fund the prevention and treatment programs needed to protect children. Factors Associated with Abuse and Neglect While knowing how many children are abused and neglected is critical to policy development, understanding the factors that contribute to maltreatment and that shape its consequences for children is crucial to the development of prevention and treatment approaches. For instance, the likelihood that an individual child will experience abuse or neglect may be influenced by characteristics of the parent or caregiver, the family’s socioeconomic situation, or the child. Caregiver characteristics such as psychological impairment, experience of child abuse or domestic violence, and attitudes toward parenting contribute directly to the occurrence of maltreatment. Aspects of the family’s social and economic situation 46 THE FUTURE OF CHILDREN – SPRING 1998 Figure 2 Substantiated Official Reports of Maltreatment in 48 States in 1994, Percentage of Victims by Type of Reported Maltreatment Neglect Type of Maltreatment Physical Other a Sexual Emotional Unknown Medical 0 10 20 30 40 50 60 Percentage of Victims b a “Other” includes abandonment, congenital drug addiction, and threats to harm the child. b Because some victims had substantiated reports for more than one type of abuse, the total does not equal 100%. The total number of substantiated victims was 1,011,628 children. Source: U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect. Child maltreatment 1994: Reports from the states to the National Center on Child Abuse and Neglect. Washington, DC: U.S. Government Printing Office, 1996, Figure 2-4. (such as unemployment, poverty, or social isolation) affect maltreatment both directly and indirectly, through their effects on parents’ psychological well-being.3 Finally, characteristics of the child (such as age and gender) may increase the potential for abuse or re-abuse, or may intensify the harmful consequences of maltreatment. Caregiver Characteristics A wide variety of characteristics of the child’s parents or caregivers have been linked to an increased likelihood of child abuse or neglect. For instance, individual attributes such as low self-esteem, poor impulse control, aggressiveness, anxiety, and depression often characterize maltreating parents or caregivers.3 Inaccurate knowledge of child development, inappropriate expectations of the child, and negative attitudes toward parenting contribute to child-rearing problems, as well. However, because cultural groups differ in the child-rearing and disciplinary practices they consider appropriate, cultural norms must also be factored in when judgments are made about child maltreatment and responses to it.24 Domestic violence involving the child’s caregiver is a problem that is more likely to contribute to physical abuse than neglect. As stated earlier, data from a 1985 national survey indicated that between 1.5 and 3.3 million children in the United States witness domestic violence each year.25 Not only is the experience of witnessing violence likely to be psychologically harmful, but several studies have found that male batterers are more likely than other men to physically abuse their children.26 Women who are victims of domestic violence are also more likely to be reported for maltreating their children.27 Substance abuse by the parent or caregiver is strongly associated with child maltreatment. Current estimates indicate that The Extent and Consequences of Child Maltreatment between 50% and 80% of families involved with child protective services are dealing with a substance-abuse problem.28 The use of crack cocaine, which rose rapidly in the late 1980s, has increased referrals to CPS agencies and has resulted in cases of both abuse and neglect that are more complex and challenging for caseworkers to handle.29 Socioeconomic Characteristics From the earliest history of child protection, concerned citizens have identified poverty as an environmental factor that contributes to child maltreatment. (See the articles by Schene and by Courtney in this journal issue.) In recent times, researchers have focused on the relationship between child maltreatment and both poverty and single-parenthood.23,30 Although child abuse and neglect occur in families of all income brackets, cases of child maltreatment are drawn disproportionately from lower-income families.31 Studies suggest that sexual abuse and emotional abuse, specifically, are not closely related to socioeconomic status.32 However, the 1993 National Incidence Study found family income to be the strongest correlate of incidence across categories of child maltreatment. Poverty was especially related to serious neglect and severe violence toward children.13 No one fully understands the links between poverty and maltreatment. The stress and frustrations of living in poverty may combine with attitudes toward the use of corporal punishment to increase the risk of physical violence. For instance, researchers have found that unemployment can lead to family stress and to child abuse.3 When a family lacks the basic resources needed to provide for a child, neglect is likely, although researchers suggest that dynamics over and above poverty (such as disorganization and social isolation) differentiate neglecting families from others.33 Indeed, most poor people do not mistreat their children. The effects of poverty appear to interact with other risk factors such as unrealistic expectations, depression, isolation, substance abuse, and domestic violence to increase the likelihood of maltreatment. Child Characteristics Studies suggest that younger children, girls, premature infants, and children with more irritable temperaments are more vulnerable to abuse and neglect. Girls are more likely to suffer from sexual abuse than are boys, but other types of maltreatment affect both sexes about equally.13 Maltreated infants and young children are significantly more likely to be reported to CPS agencies than are older children. About 16 per 1,000 children under age one were involved in substantiated reports in 1994, compared to only 9 per 1,000 adolescents ages 16 to 18. The youngest children, whose bodies are fragile, more often die from maltreatment: 45% of the maltreatment-related fatalities from 1993 to 1995 involved infants, and 85% involved children under age five.34 Consequences of Child Maltreatment During the past 30 years, the focus on the extent and nature of child maltreatment has been coupled with an increasing interest in the effects of maltreatment. The accumulated evidence indicates that children who Current estimates indicate that between 50% and 80% of families involved with child protective services are dealing with a substance-abuse problem. are maltreated often experience disrupted growth and development. Adverse effects have been identified in maltreated children’s physical, cognitive, emotional, and social development, and these adverse effects accumulate over time. While there are indications that the negative effects on development can often (but not always) be reversed, this reversal requires timely identification of the maltreatment and appropriate intervention. The psychological, emotional, or physical damage that a child suffers as a result of maltreatment depends on aspects of the abuse itself and on the child’s stage of development.35 It should be noted that most research on maltreated children comes through clinical studies of young children who have been referred for treatment, who are typically those exhibiting the most serious behavioral problems. Moreover, most of the children studied are involved with public child welfare agencies and come from families of lower socioeconomic status and 47 48 THE FUTURE OF CHILDREN – SPRING 1998 minority populations. For both reasons, the findings summarized below may not reflect the consequences of child maltreatment for the entire population of abused and neglected children.36,37 In some cases, children do not appear to exhibit significant effects from maltreatment. These children may have been buffered by personal characteristics such as optimism, high self-esteem, high cognitive ability, or a sense of hopefulness despite their circumstances. Damaging effects may be limited if the abuse occurs only once, or if a supportive adult is available who lets the child feel he or she is believed and will be As they get older, children who have been abused and neglected are more likely to perform poorly in school; to commit crimes; and to experience emotional problems, sexual problems, and alcohol/substance abuse. protected.38 In some cases, however, effects of abuse may surface long after the experience. For example, some preadolescent sexual-abuse victims do not exhibit the effects of the abusive experience until adolescence or adulthood, when they become involved in intimate relationships.39 Other children who suffer maltreatment evidence signs of serious emotional or physical harm. For some children the maltreatment experience is fatal. From 1990 to 1994, a total of 5,400 children are known to have died from an act of abuse or neglect.9 A survey of 26 states that could report the type of maltreatment that caused fatalities between 1993 and 1995 revealed that 37% of the children died from neglect, 48% died from abuse, and 15% died as a result of both types of maltreatment.34 Children who survive maltreatment are also likely to suffer serious consequences. Lasting growth retardation may result when the caregiver’s feeding of an infant becomes disturbed; this response to neglect is called nonorganic failure to thrive. Other physical sequelae can afflict victims of sexual abuse, who may become infected with sexually transmitted diseases.3 Psychological problems are prevalent among victims of maltreatment. Physically abused children tend to be aggressive toward peers and adults, to have difficulty with peer relations, and to show a diminished capacity for empathy toward others.40 Studies of neglected toddlers show that their ability to trust others is often impaired. This may lead to feelings of being unloved and unwanted, and may inhibit the development of the social skills needed to form healthy relationships with peers and adults. When a child cannot master developmental tasks (like learning to trust) at the appropriate age, the accomplishment of later tasks becomes more difficult throughout the life span.41 As they get older, children who have been abused and neglected are more likely to perform poorly in school and to commit crimes against persons. They more often experience emotional problems, depression, suicidal thoughts, sexual problems, and alcohol/substance abuse.38,42 Some children internalize reactions to maltreatment by becoming depressed or experiencing eating disorders, sleep disruption, and alcohol/drug abuse. Others externalize their reactions by engaging in physical aggression, shoplifting or committing other crimes, or attempting suicide.37,43,44 Retrospective studies of adults who were mistreated as children reveal a similar array of short- and long-term impairments.43,45,46 As can be seen from this brief description, the effects of maltreatment on children are often severe and long-lasting, although for any given child, the consequences of abuse or neglect will be shaped by the intensity, duration, and type of abuse; the presence of supportive adults; and the age of the child at the time.37,45,47,48 The fact that each child and maltreatment experience is unique means that each child requires individual assessment and tailored supports. The younger the child is at the onset of maltreatment, the more important it is to accurately assess and ameliorate the effects of the experience so that the child can recover and go on to master other life tasks successfully. Implications for Policy and Practice During the past century, U.S. society has made considerable progress in defining and The Extent and Consequences of Child Maltreatment protecting children from abuse and neglect. A century of advocacy has resulted in federal statutes providing minimum standards for the identification of child maltreatment, and financing to enable states and local communities to investigate cases of abuse and neglect and provide intervention programs. Although the total extent of child maltreatment in the United States remains unknown, studies of parents, professionals, and official records reveal that several million children suffer abuse or neglect at the hands of their caregivers every year. There is also evidence that the experience of maltreatment inhibits children’s healthy growth and development (physical, psychological, emotional, cognitive, and social), and that it impairs their functioning as adults. Considerable disagreement remains, however, over the extent to which the government should be involved in the lives of families in which children may be mistreated. Should the public CPS agency intervene when the child does not face immediate serious injury, but caregiver behaviors are likely to result in negative effects over the long run? Should CPS provide prevention or early intervention services for families that are “at risk” but not yet abusive or neglectful? While these questions are debated, most CPS agencies are unable to respond to the increasing volume of child maltreatment allegations reported by professionals and the community at large. (See the article by Waldfogel in this journal issue.) Although these agencies are charged with the responsibility for investigating reports and acting to protect children in cases of substantiated maltreatment, the National Commission on Children reported in 1991 that the current system of child protection falls far short of its goals.49 The past decade saw a substantial increase in the identification of maltreated children without a corresponding increase in resources to help these families and their children. (See the article by Courtney in this journal issue.) To cope with swelling and increasingly severe caseloads, child welfare agency administrators, supervisors, and line social workers are looking for ways to serve families more efficiently and effectively. One way that CPS agencies nationwide have responded to the imbalance between reported cases of maltreatment and agency resources is to make judgments about the cases that should receive priority for services. Currently, it is estimated that between 40% and 60% of cases in which maltreatment is substantiated receive no subsequent services.5,9 Many CPS agencies have developed risk-assessment systems or guidelines to target limited resources so the children facing the most imminent risk, at least, can be served. (See Box 2 for an example.) In practice, however, this approach often means that physical-abuse and sexual-abuse referrals are prioritized for services, since the harm to these children is usually observable and unambiguous. Victims of neglect, the form of child maltreatment most frequently reported to authorities, are likely to fall to 49 50 THE FUTURE OF CHILDREN – SPRING 1998 Box 2 Main Categories Included in Risk-Assessment Model Used in Washington State Child Characteristics Age of child Physical/mental/social disability or developmental delay Behavioral problems Self-protection, ability to resist abuse Fear of caregiver or home environment Caregiver Characteristics Victimization of other children Mental, physical, or emotional impairment Substance abuse, past or current History of abuse or neglect as a child Poor parenting skills or knowledge, inappropriate expectations Inability to nurture child Failure to recognize problem or accept responsibility Unwillingness or inability to protect child Uncooperative with child protective services (CPS) agency Parent/Child Relationship Inappropriate response to child’s behavior Poor attachment and bonding Child has inappropriate family role Severity of Child Abuse/Neglect Dangerous acts that create risk of injury Extent of physical injury or harm Extent of emotional harm Inadequate medical care, routine and in case of injury or illness Failure to provide for basic needs Inadequate supervision for child’s age Physical hazards in the home Sexual contact Chronicity of Child Abuse/Neglect Chronic or repeated maltreatment Perpetrator Access Has unsupervised access to child (in case of abuse) Has sole responsibility for care of child (in case of neglect) Social and Economic Factors Stress on caregiver Unemployed caregiver Lack of social support for caregiver Lack of economic resources Source: Washington Risk Assessment Matrix. Developed in 1987 by the Division of Child and Family Services, Children’s Administration, Department of Social and Health Services, Olympia, WA. The Extent and Consequences of Child Maltreatment the bottom of the list and receive few services. Yet the harm these children may suffer from years of chronic neglect can be more damaging and pervasive than bruising or broken bones. Even though child advocates were successful in rallying support for a federal definition of child maltreatment that included neglect and emotional injury, they have been unable to mobilize national, state, and local governments to provide the resources needed to carry out the law. Research indicates that child neglect and emotional abuse may result in as much or more harm to children than physical or sexual abuse. Yet these cumulative, long-term harms are often not addressed by the child protection system. 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